Influence of the palatine tonsil grade on the morphology of the maxillary and mandibular dental arches / Influencia del grado de las tonsilas palatinas en la morfología de los arcos dentales maxilar y mandibular

SUMMARY: Enlarged palatine tonsils and adenoids are thought to cause obstruction of the upper airway, triggering changes in breathing patterns, which in turn lead to dentofacial alterations, including malocclusions. The object of the present study was to correlate the size (grade) of the palatine tonsil with measurements of the maxillary and mandibular dental arches in children. This was an observational cross-sectional study carried out in 35 children aged between 6 and 11 years. The inter- and intra-arch parameters were measured (horizontal, vertical and sagittal analyses) by making plastercasts and then taking measurements with callipers. The tonsil size was classified in 5 grades from 0-4, using the Brodsky tonsil grading scale. The researcher was calibrated prior to carrying out the measurements. Pearson's chi-squared test was used and Pearson's correlation coefficient was calculated. The SPSS v.22.0 software was used, with a significance threshold of 5 %. Six patients were classified as grade 1, sixteen grade 2, eleven grade 3, two grade 4 and none of the patients presented grade 0.A low positive association was found between tonsil grade and the total length of the mandibular arch, a very low positive association between tonsil grade and maxillary inter-first premolar distance, total length of the maxillary arch and depth of the palatine recess.A very low negative association was found for tonsil grade and overjet, overbite, mandibular inter-permanent first molar distance, mandibular inter-first premolar distance, and mandibular and maxillary intercanine widths. No statistically significant correlation was observed for any of the measurements. No association was found between the tonsil grade and Angle's Classification, canine relationship, overjet and overbite. According to the results of this study there is no significant correlation between the dental arches and the tonsil grade.

RESUMEN: Se ha considerado que el grado del tamaño de las tonsilas palatinas y los adenoides pueden ser factores que generan obstrucción de la vía aérea superior, desencadenando cambios en el patrón de respiración, lo que provoca alteraciones dentofaciales, entre ellas, maloclusiones. El objetivo del presente estudio fue correlacionar el grado tonsilar palatino con medidas de los arcos dentales maxilar y mandibular en niños. Se realizó un estudio observacional de corte transversal. Fueron incluidos 35 niños entre 6 y 11 años de edad. Fueron medidos parámetros interarco e intra-arco (análisis transversal, vertical, sagital). Para eso fueron tomados modelos de yeso y luego las medidas fueron realizadas con un caliper. El grado tonsilar fue clasificado en 5 grados (0-5), de acuerdo a la escala de graduación de Brodsky. Para la realización de las mediciones el evaluador fue previamente calibrado. Se realizó la prueba Chi-cuadrado de Pearson, y coefi- ciente de correlación de Pearson. Se utilizó el software SPSS 22.0, considerándose umbral de significación de 5 %. Seis pacientes fueron clasificados en grado 1, dieciséis grado 2, once grado 3, dos grado 4 y ningún paciente presentó grado 0. Se encontró una asociación positiva baja entre grado tonsilar y la longitud total del arco mandibular, positiva muy baja entre grado tonsilar y distancia inter-primer premolar maxilar, longitud total del arco maxilar y profundidad de la bóveda palatina. Una asociación negativa muy baja fue encontrada para el grado tonsilar y overjet, overbite, distancia inter-primer molar permanente mandibular, distancia inter- primer premolar mandibular, ancho intercanino mandibular y maxilar. Se observó ausencia de correlación estadísticamente significativa para todas las medidas. No se encontró asociación entre el grado tonsilar y clase molar de Angle, relación canina, overjet y overbite. Según los resultados de este estudio no se aprecia una correlación significativa entre los arcos dentales y el grado tonsilar.

Adult tonsillectomy: postoperative pain depends on indications / Tonsilectomia no adulto: a dor pós-operatória depende das indicações

ABSTRACT INTRODUCTION: Intense pain is one of the most important postoperative complaints after tonsillectomy. It is often described by patients as comparable to the pain that accompanies an acute tonsillitis. Although recurrent tonsillitis is the most frequent indication for surgery, many tonsillectomies are performed due to other indications and these patients may be unfamiliar with such pain. OBJECTIVE: To verify whether individuals with recurrent tonsillitis experience different post-tonsillectomy pain intensity than those with other indications for surgery, with no history of episodes of acute tonsillitis. METHODS: A total of 61 tonsillectomies were performed under general anesthesia, using a potassium titanyl phosphate (KTP) laser (to eliminate the potential influence on the study results of forceful dissection of fibrotic tonsils in patients with history of recurrent tonsillitis) and multiple ligations of blood vessels within the tonsillar beds. The patients received 37.5 mg Tramadoli hydrochloridum + 325 mg Paracetamol tablets for 10 days. Postoperative variables included the duration of hospital stay, postoperative hemorrhage and readmission rate. The patients reported pain intensity on consecutive days, pain duration, weight loss on postoperative day 10, character, intensity and duration of swallowing difficulties, and the need for additional doses of painkillers. Healing was also assessed. Capsular nerve fibers were histologically examined in the resected tonsils by immunostainings for general and sensory markers. RESULTS: Indications for the surgery were: recurrent acute tonsillitis (34 patients), no history of recurrent tonsillitis: focus tonsil (20) and intense malodour (7). Pain intensity on postoperative days 3-4 and incidence of readmissions due to dehydration were significantly higher in the group with no history of recurrent tonsillitis. No significant differences in relative densities of protein gene product (PGP) 9.5- and calcitonin gene-related peptide (CGRP)-immunoreactive nerve fibers were observed. CONCLUSION: Patients with recurrent tonsillitis qualified for tonsillectomy reported lower pain intensity than those without recurrent tonsillitis and the pain scores were unrelated to nerve fibers density.

Resumo Introdução: Dor intensa é uma das queixas mais importantes no pós-operatório de uma tonsilectomia. Com frequência, essa dor é descrita pelos pacientes, como comparável à dor que acompanha a tonsilite aguda. Apesar da tonsilite recorrente ser a indicação mais frequente para cirurgia, muitas tonsilectomias são realizadas por outras indicações, e esses pacientes podem não estar familiarizados com essa dor. Objetivo: Verificar se indivíduos com tonsilite recorrente apresentam diferenças na intensidade dolorosa pós-tonsilectomia vs. pacientes com outras indicações para cirurgia, sem histórico de episódios de tonsilite aguda. Método: Foram realizadas 61 tonsilectomias sob anestesia geral, com o uso de um laser potassium titanyl phosphate (KTP) (para que fosse eliminada uma possível influência de uma dissecção agressiva das tonsilas fibrosadas em pacientes com história de tonsilite recorrente), e hemostasia através de ligaduras de vasos sanguíneos nos leitos tonsilares. Os pacientes foram medicados com 37,5 mg de cloridrato de tramadol + 325 mg de paracetamol (comprimidos) durante 10 dias. As variáveis pós-operatórias foram tempo de internação hospitalar, hemorragia e percentual de readmissão. Os pacientes forneceram informações sobre a intensidade da dor em dias consecutivos, duração da dor, perda de peso corpóreo no dia 10 do pós-operatório, intensidade e duração da dificuldade de deglutição, e necessidade de doses adicionais de analgésicos. A velocidade de cicatrização também foi avaliada. Fibras nervosas capsulares foram examinadas histologicamente nas tonsilas resecadas com o uso de imunocorantes para marcadores de fibras nervosas gerais e de sensibilidade. Resultados: As indicações para a cirurgia foram: tonsilite aguda recorrente (34 pacientes), ausência de história de tonsilite recorrente - Tonsilite focal (20) e halitose (7). A intensidade da dor nos dias 3-4 do pós-operatório e a incidência de reinternações em decorrência de desidratação foram significativamente mais altas no grupo sem história de tonsilite recorrente. Não foram observadas diferenças significantes nas densidades relativas de fibras nervosas imunorreativas para protein gene product (PGP) 9.5 e calcitonin gene-related peptide (CGRP). Conclusão: Os pacientes com tonsilite recorrente e qualificados para tonsilectomia informaram menor intensidade da dor em relação aos pacientes sem histórico se tonsilite recorrente, e os escores para dor não apresentaram relação com a densidade das fibras nervosas.

Indicaciones y complicaciones de la adenoidectomia y tonsilectomía en el Hospital Carlos Andrade Marín / Instructions and complications of adenoidectomy and tonsillectomy in the Carlos Andrade Marin Hospital

Introducción: la adenoidectomía y la tonsilectomía (amigdalectomía) son intervenciones quirúrgicas muy frecuentes en Otorrinolaringología. Sin embargo, muchas veces se las realiza sin un criterio valorable y de forma indiscriminada. Aunque en principio las indicaciones generales para estas intervenciones son los procedimientos infecciosos u obstructivos, en la actualidad también se contempla su utilidad en otros cuadros poco comunes como la sospecha de malignidad amigdalina, halitosis de origen amigdalino, nefropatía por IgA y Síndrome PANDAS (Síndrome de Desorden Neurosiquiátrico Pediátrico Autoinmune asociado con Estreptococo). A partir de septiembre de 2009, el Hospital Carlos Andrade Marín amplió la cobertura de atención a la población pediátrica, aumentando el número de estas cirugías en nuestro Servicio. El objetivo de este estudio fue, revisar las indicaciones y complicaciones de estos procedimientos basados en la experiencia de nuestro servicio en la población pediátrica y adulta y cotejarlas con los consensos internacionales. Materiales y métodos: se realizó un estudio descriptivo, retrospectivo utilizando los expedientes clínicos de los pacientes intervenidos en el Servicio de Otorrinolaringología del Hospital Carlos Andrade Marín en el período de mayo 2010 a diciembre 2012. Se analizaron datos demográficos, indicaciones para la realización de cirugía y complicaciones presentadas. Resultados: se intervinieron un total de 120 pacientes en este período. No hubo diferencia en el sexo de los pacientes. El promedio de edad en Tonsilectomía en adulto fue 26 años y en niños, 5 años; en la Adenoidectomía el promedio de edad fue 4.5 años y en los casos de adenoidectomía + tonsilectomía combinada, la edad promedio fue 5 años de edad. Se realizó tonsilectomía en el 45% de los pacientes, adenoidectomía en 30% y adenoidectomía + tonsilectomía combinada en 25% de los casos. La principal indicación para realización de tonsilectomía fue la amigdalitis recurrente (57% casos), mientras que para la adenoidectomía fue la hipertrofia adenoidea obstructiva (60% casos). La tasa total de complicaciones en tonsilectomía fue del 11% (6 / 54); correspondiendo a 4 casos de sangrado precoz (7%), y 2 casos de epistaxis posterior, secundarios a intubación nasotraqueal. En adenoidectomía, la tasa total de complicaciones fue del 5% (2/36), 1 caso por epistaxis severa, y 1 caso por desgarro de mucosa de nasofaringe que fue controlado durante cirugía. No hubo complicaciones en los casos de adenoidectomía + tonsilectomía combinada. No se presentaron decesos en ningún grupo. Conclusiones: la adenoidectomía y la tonsilectomía son procedimientos quirúrgicos eficaces y con baja tasa de complicaciones si se los emplea de acuerdo a los criterios establecidos en consensos internacionales. Nuestra experiencia quirúrgica está acorde a ello.

Introduction: adenoidectomy and tonsillectomy are very common surgeries in Otolaryngology. However, often they are done without a valuable criterion and indiscriminately. Although in principle the general indications for these interventions are infectious or obstructive procedures, currently its utility is also required by other rare cases as suspected tonsillar malignancy, halitosis of tonsillar origin, IgA nephropathy syndrome and PANDAS (Syndrome Pediatric Autoimmune Neuropsychiatric Disorder associated with Streptococcus). From september 2009, Carlos Andrade Marín Hospital expanded coverage for care in the pediatric population, increasing the number of these surgeries in our Service. The aim of this study was to review the indications and complications of these procedures based on the experience of our service in the pediatric and adult population and to align with international consensus. Materials and methods: a descriptive and retrospective study was conducted using the medical records of patients treated in the Department of Otolaryngology, Carlos Andrade Marín Hospital in the period from may 2010 to december 2012. Demographic data, indications for surgery and complications were analyzed. Results: a total of 120 patients were operated during this period. There was no difference in sex of patients. The average age in adult Tonsillectomy was 26, and in children, 5 years; the mean age in Adenoidectomy was 4.5 years and in cases of combined tonsillectomy and adenoidectomy, the average age was 5 years old. Tonsillectomy was performed in 45% of patients, 30% adenoidectomy, and combined tonsillectomy and adenoidectomy in 25% of cases. The main indication for performing tonsillectomy was recurrent tonsillitis (57% cases), while for adenoidectomy was obstructive adenoid hypertrophy (60% cases). The overall complication rate in tonsillectomy was 11% (6/54); corresponding to 4 cases of early bleeding (7%), and 2 cases of posterior epistaxis by nasotracheal intubation. In adenoidectomy, the overall complication rate was 5% (2/36), 1 case of severe epistaxis, and 1 case by tearing of the nasopharyngeal mucosa that was controlled during surgery. There were no complications in cases of adenoidectomy + combined tonsillectomy. No deaths occurred in either group. Conclusions: adenoidectomy and tonsillectomy are effective surgical procedures and have low rate of complications if they are used according to the criteria established by international consensus. Our surgical experience is accordingly.

Poliposis linfangiomatosa de amígdalas palatinas y adenoides: reporte de un caso / Lymphangiomatous polyps of adenoids and palatine tonsils: one case report

Los pólipos linfangiomatosos son malformaciones congénitas de tipo hamartomatosas caracterizados histológicamente por una proliferación linfática vascular con distintos grados de componente fibroso, adiposo y linfático, cubiertos por un epitelio escamoso. Dado a que se conocen por distintos nombres en la literatura, sólo se han descrito alrededor de 30 casos de pólipos linfagiomatosos como tal. De etiopatogenia desconocida, se presentan como una masa polipoidea o papilomatosa en las amígdalas palatinas, con sintomatología variable. Su diagnóstico definitivo es histológico tras una resección completa. No se han reportado casos de malignización ni recurrencia. En el presente trabajo se reporta el caso de un paciente de 5 años con historia de crecimiento amigdalino bilateral de dos años de evolución. La biopsia definitiva demuestra una poliposis linfangiomatosa de amígdalas palatinas y adenoides.

Lymphangiomatous polyps are hamartomatous congenital malformations. They are histologically characterized by a vascular lymphatic proliferation associated with fibrous, adipose and lymphatic components covered by squamous epithelium. There are only 30 cases described in the literature by the name of lymphangiomatous polyp, since it has multiple denominations. Even though their etiopathogenesis is unknown, their clinical presentation is described as a polypoid mass in the palatine tonsils, which may have multiple manifestations. The diagnosis is made histologically after complete resection. There have not been reports of malignant transformation nor recurrence. We present a case of a five year old patient with history of bilateral palatine tonsil growth. Final biopsy described lymphangiomatous polyps of adenoids and palatine tonsils.

Respiração oral e alteração de fala em crianças / Oral breathing and speech disorders in children

OBJETIVO: Verificar alterações na fala em crianças respiradoras orais e relacioná-las com o tipo respiratório, a etiologia, o gênero e a idade. MÉTODO: Foram avaliados 439 respiradores orais com idade entre quatro e 12 anos. Considerou-se atraso no desenvolvimento de fala a presença de alterações em crianças acima de cinco anos de idade. As alterações observadas foram interposição de língua (IL), ceceio frontal (CF), troca articulatória (TA), omissões (OM) e ceceio lateral (CL). Relacionou-se etiologia da respiração oral, gênero, idade, tipo respiratório e alterações de fala. RESULTADOS: Alterações de fala foram diagnosticadas em 31,2% dos pacientes sem relação com o tipo respiratório: oral ou misto. Maior frequência de trocas articulatórias e mais de uma alteração de fala ocorreram no gênero masculino. IL foi documentada em 53,3% pacientes, seguida por TA em 26,3% e CF em 21,9%. Concomitância de duas ou mais alterações de fala ocorreu em 24,8% das crianças. CONCLUSÃO: Respirar pela boca pode afetar o desenvolvimento da fala, a socialização e o desempenho escolar. A detecção precoce da respiração oral é essencial para prevenir e minimizar seus efeitos negativos sobre o desenvolvimento global dos indivíduos.

OBJECTIVE: To assess speech alterations in mouth-breathing children, and to correlate Mouth breathing; them with the respiratory type, etiology, gender, and age. METHOD: A total of 439 mouth-breathers were evaluated, aged between 4 and 12 years. The presence of speech alterations in children older than 5 years was considered delayed speech development. The observed alterations were tongue interposition (TI), frontal lisp (FL), articulatory disorders (AD), sound omissions (SO), and lateral lisp (LL). The etiology of mouth breathing, gender, age, respiratory type, and speech disorders were correlated. RESULTS: Speech alterations were diagnosed in 31.2% of patients, unrelated to the respiratory type: oral or mixed. Increased frequency of articulatory disorders and more than one speech disorder were observed in males. TI was observed in 53.3% patients, followed by AD in 26.3%, and by FL in 21.9%. The co-occurrence of two or more speech alterations was observed in 24.8% of the children. CONCLUSION: Mouth breathing can affect speech development, socialization, and school performance. Early detection of mouth breathing is essential to prevent and minimize its negative effects on the overall development of individuals.